Professional Documents
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1210-0016
(Form 5500) This schedule is required to be filed under section 104 of the Employee
Retirement Income Security Act of 1974, referred to as ERISA, except when
Department of the Treasury attached to Form 5500-EZ and, in all cases, under section 6059(a) of the
Internal Revenue Service Internal Revenue Code, referred to as the Code. This Form Is Open to
Department of Labor Public Inspection
Pension and Welfare Benefits Administration © Attach to Form 5500, 5500-C/R, or 5500-EZ if applicable. (except when attached
Pension Benefit Guaranty Corporation © See separate instructions. to Form 5500-EZ)
For calendar plan year 1995 or fiscal plan year beginning , 1995, and ending , 19
© If an item does not apply, enter “N/A.” © Round off amounts to nearest dollar.
© Caution: A penalty of $1,000 will be assessed for late filing of this report unless reasonable cause is established.
A Name of employer/plan sponsor as shown on line 1a of Form 5500, 5500-C/R, or 5500-EZ B Employer identification number
If the actuary has not fully reflected any regulation or ruling promulgated under the statute in completing this schedule,
check the box and see instructions
For Paperwork Reduction Act Notice, see the Instructions for Form 5500, 5500-C/R or 5500-EZ. Cat. No. 13507E Schedule B (Form 5500) 1995
Schedule B (Form 5500) 1995 Page 2
3 Contributions made to the plan for the plan year by employer(s) and employees:
(a) (b) (c) (a) (b) (c)
Month-Day-Year Amount paid by Amount paid by Month-Day-Year Amount paid by Amount paid by
employer employees employer employees
5 Actuarial cost method used as the basis for this plan year’s funding standard account computation:
a Attained age normal b Entry age normal c Accrued benefit (unit credit)
d Aggregate e Frozen initial liability f Individual level premium
g Individual aggregate h Other (specify) ©
i Has a change been made in funding method for this plan year? Yes No
j If line i is “Yes,” was the change made pursuant to a Revenue Procedure with respect to which all
conditions for approval were satisfied? Yes No
k If line i is “Yes,” and line j is “No” enter the date of the ruling letter approving the
change in funding method Month Day Year
6 Checklist of certain actuarial assumptions: Pre-retirement Post-retirement
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